Utilization Management Physician Advisor, CA Licensed (Part Time)

Alignment Health

2d•Remote

About The Position

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. Utilization Management Physician Advisor works with Senior Medical Officers, Regional Medical Officers, Extensivists, the Healthcare Services Team (Case managers, Social Workers, Utilization Managers) to develop and implement methods to optimize use of Institutional and Outpatient services for all patients while also ensuring the quality of care provided. Through remote access to our web-based Portal, physician advisors will complete clinical reviews for medical necessity, treatment appropriateness and compliance. MUST HAVE CALIFORNIA LICENSE

Requirements

MUST HAVE CALIFORNIA LICENSE
Required: Minimum of 3 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization / case management, or medical staff governance required
Required: Completion of medical school and specialty residency (preferably in internal medicine).
Required: Applicants must have current, non-restricted licensure as required for clinical practice in the state of California.
Required: Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management.
Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations.
Dedication to the delivery of high-quality, cost-effective, efficient patient care services
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.

Nice To Haves

Preferred: Experience as a Physician Advisor or Medical Director a plus
Preferred: Board-certification

Responsibilities

Perform medical necessity utilization reviews primarily for inpatient and post-acute cases with some outpatient / pre-service reviews as needed in accordance with UM guidelines
Lead concurrent review activities, including rounds, peer-to-peers, and utilization management strategies to improve clinical and efficiency outcomes
Serve as a clinical leader and educator for the nursing / care management team
Process claims reviews, appeals, and second-level reviews as needed in compliance with Medicare (NCD, LCD), internal, and third-party guidelines (e.g., MCG) for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
Acts as a liaison between the medical staff, utilization review team, and 3rd parties to effectively promote clinically necessary and efficient utilization of care
Serves as a Physician member of the utilization review team.
Work with Interdisciplinary Teams to help manage complex or high risk cases
Contributes to development of clinical strategies to improve member outcomes, efficiency metrics, and quality outcomes
Duties may include serving on committees as needed, such as quality, utilization management, credentialing, etc
Other duties as may be assigned to the medical director.
Oversees assigned staff, if any. Responsibilities may include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.